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This article reviews the recent advances or nerve-oriented surgical procedures in the treatment of the spastic upper limb. The idea to intervene on the nerve is not recent, but new trends have developed in nerve surgery over the past few years, stimulating experiments and research. Specific surgical procedures involving the nerves have been described at different levels from proximal to distal: at the cervical spinal cord and the dorsal root entry zone (rhizotomy), at the level of the roots (contralateral C7 transfer) or in the peripheral nerve, within the motor trunk (selective neurectomy) or as its branches penetrate the muscles (hyperselective neurectomy). All of these neurosurgical procedures are only effective on spasticity but do not address the other deformities, such as contractures and motor deficit. Additional procedures may have to be planned in conjunction with nerve procedures to optimize outcomes. [ABSTRACT FROM AUTHOR]

In the last decade there has been incredible interest and advancement in the surgical care of adult patients with upper motor neuron (UMN) injuries. Spasticity represents a prevalent and debilitating feature of UMN syndrome, which can result from cerebral palsy, spinal cord injury, cerebrovascular accident and traumatic or anoxic brain injury. While several diagnostic tools and management strategies have been described for upper limb spasticity, evidence-based practice guidelines do not currently exist due to low patient volume and a paucity of surgeons routinely performing surgeries in UMN syndrome patients. As such, expert consensus may help provide guidance for patients, therapists and clinicians alike. In this article an expert panel was assembled, and the Delphi method was utilized to present diagnostic considerations, define operative indications, discuss surgical treatment modalities and encourage a standard set of outcome measures for patients with upper extremity spasticity. [ABSTRACT FROM AUTHOR]

Purpose: Nerve transfers represent an innovative tool in the surgical treatment of upper limb paralysis. Well-documented for brachial plexus sequalae and under evaluation for tetraplegic patients, they have not yet been described for spastic upper limbs. The typical spastic deformity involves active and spastic flexor, adductor and pronator muscles, associated with paralysed extensor and supinator muscles. Experience with selective neurectomy has shown an effective decrease in spasticity together with preservation of muscle strength. We conceptualized a combination of neurectomy and nerve transfer, by performing a partial nerve transfer from a spastic elbow flexor muscle to a paralyzed wrist extensor muscle, hypothesizing that this would reduce the spasticity of the former and simultaneously activate the latter. Methods: Ten cadaveric dissections were performed in order to establish the anatomic feasibility of transferring a motor branch of the brachioradialis (BR) onto the branch of the extensor carpi radialis longus (ECRL) or brevis (ECRB). We measured the emergence, length, muscle entry point and diameter of each branch, and attempted the transfer. Results: We found 1–4 motor nerve for the BR muscle and 1–2 for the ECRL muscle. In all cases, the nerve transfer was achievable, allowing a satisfactory coaptation. The ECRB branch emerged too distally to be anastomosed to one of the BR branches. Conclusion: This study shows that nerve transfers from the BR to the ECRL are anatomically feasible. It may open the way to an additional therapeutic approach for spastic upper limbs. [ABSTRACT FROM AUTHOR]

Hyperselective neurectomy (HSN) procedures in the spastic upper limb aim to reduce tone by excising some branches of the involved peripheral motor nerves, at the point of entry of each motor ramus into the target muscle. In this prospective study, 42 patients with upper limb spasticity were treated by HSN for the muscles of elbow flexion, forearm pronation and wrist flexion and evaluated for their short-term results (average 6 months) and long-term outcomes (average 31 months). Results at both time points showed an effective reduction of the spastic tone, with no decrease of muscle strength in the operated spastic muscles. Comparison of results between the two time points showed durability of the improvement, which remained statistically significant despite a slight relapse in spasticity. The results of HSN compare favourably with the other techniques of partial neurectomy; however, the technique requires a detailed knowledge of upper limb motor anatomy. Level of evidence: II [ABSTRACT FROM AUTHOR]

Purpose: Spasticity of the first web space is common in upper limb spasticity. Selective neurectomy is one of the treatments that can reduce spasticity. The purpose of this study was to describe the variations of the deep motor branch of the ulnar nerve for the adductor pollicis (AP) and the first dorsal interosseous muscle (DIO) to assess the feasibility of selective neurectomy and suggest an ideal surgical approach. Methods: The deep branch of the ulnar nerve (DBUN) was dissected in 21 hands. Measurements included the distance between the point of passage of the DBUN between the two heads of the adductor and three anatomical landmarks: the bi-styloid line, the flexor carpi radialis and the pisiform bone, and the number and mode of divisions of each branch. Results: The point of passage of the DBUN between the two heads of the adductor is very constant respective to the landmarks. The DBUN gives off 1–3 branches each for the oblique head of the AP, the transverse head, and the first DIO. Muscles receive more than one branch in 95% cases for the oblique head and 62% of cases for the transverse head, and 100% for the DIO. Conclusions: This anatomical study suggests that selective neurectomy is feasible for the AP and first DIO muscles in most cases. An ideal approach for selective neurectomy of these muscles should start from the point of passage of the DBUN between the two heads of the AP. This point is easily identified with the help of the described landmarks. [ABSTRACT FROM AUTHOR]

Forearm muscles can undergo contracture for a number of reasons, including spasticity. This deformity is amenable to surgical treatment in select cases. Among the different techniques available, fractional lengthening of the forearm flexor muscles involves multiple tenotomies at the musculotendinous junction. We studied the anatomy of the musculotendinous junction of all forearm flexor muscles to analyze the topography and extent of muscle-tendon overlapping for each muscle and to determine the area where fractional lengthening can be performed safely. Dissections were performed on 20 fresh cadaveric upper limbs. For each muscle, we defined and measured the total overlapping zone, "corrected" overlapping zone, and useful zone (UZ), along with 3-dimensional mapping of the location of each tendon with respect to the muscles' fibers. With regard to the wrist flexors, the average UZ was very short for the flexor carpi radialis (3.5 cm) and very long for the flexor carpi ulnaris (12.2 cm). With regard to the finger flexors, the UZ of the superficialis tendons varied greatly (2.7–5.9 cm), whereas it was relatively constant for the profundi (7.6 cm) and flexor pollicis longus (6.5 cm). Fractional lengthening is dependent on the anatomy of the musculotendinous junction of each individual muscle. For muscles with a relatively short and variable UZ (flexor carpi radialis, flexor digitorum superficialis [FDS] II, and FDS IV), the feasibility of the procedure must be carefully evaluated intraoperatively. For FDS V, which constantly displays a very short UZ, with a thin and fragile tendon, the procedure may be risky and unreliable. When considering fractional lengthening of the forearm muscles, differences between the tendons should be considered, and surgeons should be prepared for alternative approaches, especially for FDS V. [ABSTRACT FROM AUTHOR]